Errors in obstetric and gynecological practice. When a doctor can only maim... Diagnosis of infectious and inflammatory diseases

L.V. Terentyeva, G.A. Pashinyan FORENSIC MEDICAL EXAMINATION OF ADVERSE OUTCOMES IN OBSTETRIC AND GYNECOLOGICAL PRACTICE

Department of Forensic Medicine (head of the department - Prof. G.A. Pashinyan) MGMSU

This article presents the results of a comprehensive clinical, forensic and medico-legal analysis of adverse outcomes in the provision of obstetric and gynecological care.

Key words: adverse outcomes, obstetrics and gynecology, forensic medicine.

L.V.Terentyeva, G.A.Pashinyan FORENSIC-LEGAL EXAMINATION OF UNFAVORABLE OUTCOMES IN OBSTETRICAL AND GYNECOLOGICAL PRACTICE Moskow

The results of complex clinical and forensic-legal analysis of unfavorable outcomes during obstetrical and gynecological rendering are devoted in the article.

Key words: unfavorable outcomes, obstetric and gynecologic, forensic medicine.

The current development of medicine in the emerging social conditions allows us to assert that one of the pressing problems of the modern healthcare system is the issue of the volume and quality of medical care, as well as the responsibility of medical workers in case of unfavorable outcomes. Great importance is now attached to this problem all over the world.

Recently, there has been a significant increase in cases of patients who have received inadequate medical care to one degree or another, turning to various judicial authorities, which is confirmed by the analysis of commission examinations carried out at the Bureau of Forensic Medical Examination of Moscow. One of the leading places in the number of civil claims is occupied by obstetrics and gynecology. There is a significant increase in such examinations (in 1995, 5 examinations were carried out, and in 2000 - 17, in 2002 - 24).

According to cumulative WHO data, it has been established that more than 200 million women become pregnant every year in the world. In just over half of them, pregnancy ends in childbirth. 570-600 thousand die from abortions, ectopic pregnancy, bleeding, eclampsia, and sepsis. Another 500 thousand women become disabled due to trauma during childbirth and postpartum complications.

Thus, the relevance of studying the problem of forensic medical examination of adverse outcomes of medical care has intensified, and clinical and expert theory and practice, as well as the field of health insurance, are experiencing a lack of information about it. This information is also important for predicting what types of legal liability will prevail in medicine in the coming years.

We analyzed medical documentation (medical histories, outpatient records, commission examination reports) for unfavorable outcomes in the provision of obstetric and gynecological care to 75 patients to identify the reasons underlying these situations at various stages of the treatment and diagnostic process.

In parallel, we conducted an anonymous survey of obstetrician-gynecologists working in medical institutions of various forms of ownership and their patients using a random sampling method. The purpose of the

testing was to determine the relevance of the issue of studying medical and legal norms regulating the activities of doctors, determining the level of legal literacy of patients, as well as determining the causes of conflicts and measures to prevent them.

The analysis led to the following results.

According to our data, in 1993-2000, the factors supporting the high level of adverse outcomes in obstetric and gynecological practice were joined by the factor of increasing the number of obstetric complications (bleeding and gestosis) and the incidence of somatic diseases in pregnant women. In conditions of increasing frequency of pregnancy complications, measures for their timely detection and prevention are important; for differentiated planned hospitalization of pregnant women for delivery in an obstetric hospital, corresponding to the risk of possible complications. So, according to our data, background extragenital morbidity occurs in 91% of cases of all unfavorable outcomes, i.e. the development of obstetric pathology is layered on the initially decompensated state of the body systems.

As for gynecological diseases, according to our data, in the analyzed group of women, they occur in 81% of cases. At the same time, the most unfavorable outcomes that resulted in the death of a woman have a positive correlation with the number of abortions and a history of inflammatory diseases.

We see the greatest reserves that can reduce the number of adverse outcomes in obstetrics in optimizing the management of patients in the outpatient department (antenatal clinics). Thus, we found that 49% of women who filed a lawsuit in court refused the treatment offered to them in the 1st, 2nd and 3rd trimesters of pregnancy.

In 53% of all cases related to improper provision of obstetric and gynecological care, patients were admitted to the hospital on an emergency basis. Moreover, more than half of the cases that led to emergency hospitalization could be recognized at the outpatient stage.

In addition, the timing of a particular manipulation (the time of active intervention) that led to an unfavorable outcome is of no small importance.

According to our data, most of these cases occur at night or in the early morning hours, holidays and weekends, as well as the second half of Friday, when for one reason or another the attention of doctors is dull. According to foreign literature, the continuous work of doctors working in an urgent specialty (obstetricians-gynecologists) should not exceed 6 hours, while according to domestic standards, daily duty lasts 12 hours without the right to sleep. On weekends and holidays, as a rule, some specialists are absent from hospitals, mainly more experienced managers, who on a normal day could provide the necessary assistance in a timely manner. For this same reason, most adverse outcomes occur on Friday, when most doctors have already left the hospital.

There is no clear consensus on the management of childbirth. In more than 50% of cases of all adverse outcomes examined by us, the birth management plan, in the opinion of the expert commission, was drawn up without taking into account abdominal birth. At the same time, modern requirements of perinatal obstetrics imply a more careful delivery.

After the data from an independent analysis of adverse outcomes in obstetric and gynecological practice, it is interesting to present the opinion of obstetricians and gynecologists themselves, based on data from an anonymous survey.

Thus, 68% of doctors consider the main reason for unfavorable outcomes in their practice to be the lack of an individual approach to the patient and an objective assessment of their capabilities, and the lack of a high level of equipment in medical institutions and the availability of modern medications is given secondary importance.

As our study showed, the greatest number of adverse outcomes in obstetric and gynecological practice occur in the period between 10 and 20 years of work for doctors (57% of cases, respectively), i.e. during the transition from the level of additional professionals to professionals. A large percentage (32%) of unfavorable outcomes among doctors with up to 10 years of work experience is explained by qualitative changes in professional status and activities. Working conditions are complicated by the emergence of extreme situations that arise during the provision of urgent care to patients in critical condition, in which responsible independent decisions have to be made. Having 15-20 years of work experience, doctors

over time, they mature to the status of a responsible doctor on duty in obstetric and gynecological hospitals, however, not all doctors are ready to work in such conditions, especially doctors of the outpatient obstetric service, who are deprived of appropriate training in a hospital setting. In an extreme situation, they show inertia of thinking in making quick and adequate decisions, which leads to diagnostic and treatment errors. More than half of all doctors (51% in obstetric cases and 54% in gynecological cases) had the highest or first qualification category and significant work experience. These data are quite comparable with the data referred to in his works by Yu.D. Sergeev (1988), and confirms his point of view that cases of inadequate care are more common among doctors with significant professional experience.

Among the adverse outcomes in gynecological practice, according to our data, the main part (71.5%) is due to complications of abortion. Moreover, the patients have a burdened somatic (68% of cases) and obstetric-gynecological (89.6% of cases) history. Thus, to reduce adverse outcomes in gynecological practice, it is advisable to eliminate the reasons why abortions in our country are performed 3 times more often than in Western European countries, rather than looking for reserves in improving the technique of the operation itself.

When conducting examinations related to the correctness of the provision of obstetric and gynecological care, the expert commission in 80% of cases identified deficiencies in diagnostics and treatment tactics, due not only to objective diagnostic difficulties, but also to underestimation of the severity of the patients’ condition, and the lack of timely and complete examination.

In general, most of the shortcomings in diagnostic and therapeutic care are associated with the lack of an individual approach to the patient; basically, an average approach prevails, which in most cases ceases to justify itself.

However, in the overwhelming majority of cases, the noted deficiencies in the provision of obstetric and gynecological care were not put into a causal relationship with the adverse outcome of pregnancy or childbirth, and thus did not represent prospects in terms of litigation, although they were extremely labor-intensive and required a lot of time and effort when carrying them out.

Currently, the Russian doctor remains in a disadvantageous legal position compared to the patient, upon whose application seven authorities (territorial health authorities, insurance company, prosecutor's office, court, forensic medical examination bureau, professional association, independent medical examination, ethical committee). In the context of such a legislative approach to assessing the business reputation of medical workers, the hope for sincere and voluntary recognition of professional errors by doctors is a chimera, which completely coincides with our data (only 30% of surveyed obstetricians-gynecologists indicate medical errors made in the medical (childbirth) history ).

For this reason, in the overwhelming majority of cases, “working on mistakes” among obstetricians and gynecologists comes down to denying the possibility of preventing a death or justifying it by “objective” factors. Such a reaction from doctors is understandable, but it is not constructive and deprives them of the opportunity to acquire new knowledge from their own negative experience, which subsequently leads to repeated repetition of similar medical errors.

Against the backdrop of an increase in the level of demands placed by patients on the work of obstetricians and gynecologists (noted by 73% of patients), only a third of patients are satisfied with the quality of the doctors’ work.

The main reason for dissatisfaction with the quality of medical services is the low culture of patient care, which was almost twice as often identified by respondents as the professional level of obstetricians and gynecologists.

The main medical and legal document that guarantees protection for the doctor in all higher authorities and in court is a correctly completed medical history (careful maintenance of technological medical documentation, including with emphasis on the features of diagnosis, treatment and features of relations with patients; the presence of recorded written informed voluntary consent or refusal to intervene in medical documents, especially in patients with a high likelihood of making claims (in patients with multiple background or concomitant diseases); careful development and execution of an agreement for the provision of paid medical services and an informed block describing typical and probable adverse outcomes of this type medical care).

The level of legal literacy of obstetrician-gynecologists looks simply catastrophic: only 40% of them know the regulatory documents regulating their professional activities, and only four doctors have completed medico-legal training courses for doctors.

This situation is used by a number of patients and their lawyers as an excellent opportunity to make money from the low legal literacy of doctors, and consequently, their legal defenselessness.

Moreover, our anonymous survey of patients showed that more than half of the patients surveyed (63%) know their rights, of which a third (24%)

Literature

1. Akopov V.I., Bova A.A. Legal basis for the activities of a doctor. - Expert Bureau. - M., 1997. - pp. 102-164.

2. DiMatteo M. R., Dante DiNicolu D.//Med. Care. -1991. -Vol. 19, N 8. - p. 829-842.

3. Sergeev Yu.D. The medical profession: legal foundations. - Kyiv: VSh Publishing House, 1988.-206 p.

4. Maternal mortality and ways to reduce it: Material of the 2nd National Assembly "Protection of reproductive health of the population" - M., 2000.-p.45-47

5. Abramova G.A., Yudchits Yu.A. Psychology in medicine: Textbook. -M.: Publishing House LPA Department-M, 1998. - 272 p.

A.A. Khalikov ON THE QUESTION OF THE NECESSITY TO CONSIDER THANATOGENESIS IN POST-MORTH THERMOMETRY

Department of Forensic Medicine (head of the department - Prof. V.I. Viter)

Izhevsk State Medical Academy

The article presents the results of an original study of post-mortem cooling from the perspective of taking into account variants of thanatogenesis - the shock reaction of the body preceding death. The values of thermal constants of the exponential cooling stage for various diagnostic zones are considered.

Key words: thermometry, shock, thanatogenesis, post-mortem cooling.

ABOUT NECESSITY OF THANATOGENESIS CONSIDERATION IN POSTMORTEM THERMOMETRY

There are presented the results of original investigation of postmortem cooling with taking into account of different thanatogenesis variants, in particular shock reaction of organism, which precede death. Exponential constants for different diagnostic regions are considered.

Key words: thermometry, shock, thanatogenesis, postmortem cooling.

Establishing the duration of death by degree of determination, many researchers tried to move

neither the severity of cadaveric changes has lost its ty from the subjective assessment of the results of studying cadaveric

meanings up to now. To increase the accuracy of changes to objective methods of their study. At

learns about their rights from television programs, 18% read relevant literature, and 21% of patients already have personal experience in defending their rights, which indicates the high legal literacy of patients.

Patients in most cases prefer to contact, first of all, the doctor who treated them, demanding that the defects of the previous treatment be eliminated. Only a small proportion of patients (10%) are ready to go to court and demand civil or criminal liability from the doctor (16%). However, a significant number of patients are ready to turn to the administration of this medical institution in order to compensate for moral and material damage (37% of cases).

This fact allows us to conclude that further informatization of patients in the field of protecting their rights, which both the press and television are aimed at, may in the near future lead to an even greater number of conflict situations between doctors and patients.

Our analysis of regulatory documents regulating the professional activities of obstetricians and gynecologists allows us to clearly see that they are all focused primarily on protecting the interests of the consumer. Therefore, only strict observance by an obstetrician-gynecologist of all requirements for his professional activity, based on knowledge of the legal documents regulating it, can ensure protection from unfounded claims made by patients.

Diagnosis of pregnancy. Oncological alertness.

M.V. Mayorov, obstetrician-gynecologist of the highest category, antenatal clinic of city clinic No. 5, Kharkov

Bene facit, qui ex aliorum erriribus sibi exemplum sumit (“He who learns from the mistakes of others does well” – lat.)

The well-known maxim “Errare humanum est” (“To err is human” – Latin) fully applies to representatives of the medical profession. An error is understood as the actions of a doctor, which are based on the imperfection of modern medical science; working conditions that are not optimal; insufficient qualifications or inability to use available data to make a diagnosis. The defining sign of an error is the inability for a given specialist to foresee and prevent its consequences (N.V. Elshtein, 1991).

Objective circumstances leading to an error should be considered conditions under which it is not possible to conduct a particular study. Significant objective reasons for errors include, first of all, the inconsistency of individual postulates and principles in the field of theoretical and practical medicine, due to which views on the etiology, pathogenesis, and understanding of the essence of many diseases change from time to time. Errors caused by medical ignorance are the most numerous and especially significant in their interpretation. In each individual case, the question of classifying a doctor’s actions as an error, especially when differentiating ignorance due to insufficient qualifications and elementary medical ignorance, is decided based on the specific features of the course of the disease, duration of observation, examination capabilities, etc. It seems wrong to always associate the subjective causes of diagnostic errors only with the qualifications of specialists. Undoubtedly, it is difficult to overestimate the importance of knowledge for correct diagnosis. However, qualification is not only the training of a doctor, but also the ability to accumulate knowledge, understand, as well as apply it, which largely depends on the individual qualities, intelligence, character traits and even temperament of a particular specialist. N.I. Pirogov wrote: “Life does not fit into narrow frameworks, doctrines, and its changeable casuistry cannot be expressed by any dogmatic formulas.”

Taking into account the specifics of outpatient obstetrics and gynecology practice, as well as the fact that “Ignoti nulla curatio morbid” (“You cannot treat an unrecognized disease” - lat.), we will try to group and consider the most typical diagnostic errors.

Diagnosis of pregnancy

So, a considerable number of them are connected with pregnancy diagnosis. Several years ago, when the use of various highly sensitive human chorionic gonadotropin (hCG) tests and ultrasound examinations (US) were the exception rather than the rule, these errors were widespread and quite common. Overdiagnosis of intrauterine pregnancy caused a woman mainly psychological trauma, and its untimely diagnosis was fraught (not only in a figurative sense!) with missed deadlines for performing an artificial abortion, late registration at the antenatal clinic, etc. All of the above, naturally, does not help strengthen the positive image of the doctor. Late diagnosis of progressive ectopic pregnancy, as is known, sometimes leads to very serious consequences, for example, hemorrhagic shock due to rupture of the fetal sac (most often the pregnant tube).

The use of modern highly sensitive tests in combination with ultrasound, which should be performed by a qualified obstetrician-gynecologist, and not by a “general specialist in ultrasound diagnostics”, allows us to avoid gross diagnostic errors. For example, a positive hCG urine test with an “empty” uterine cavity indicates an urgent need for urgent hospitalization of a patient with a well-founded suspicion of an ectopic pregnancy.

A form of ectopic pregnancy called cervical pregnancy, is quite rare, but very dangerous. Usually in the early stages it manifests itself with bleeding, which is associated with the destructive effect of chorion on the vessels of the cervix. Bloody discharge or bleeding is often mistakenly regarded by the doctor as an interruption of a normal intrauterine pregnancy, and only barrel-shaped cervix may serve as a sign of cervical localization of the fertilized egg. However, such changes in the cervix are sometimes considered as a manifestation of an incipient abortion, when the fertilized egg, upon being born, descends into the lumen of the distended cervical canal with an unopened external os. Indeed, in such cases the neck may also have a barrel shape. The existing hypertrophy of the cervix, as well as uterine fibroids in combination with pregnancy, greatly complicates the differential diagnosis.

It is better to suspect a cervical pregnancy where there is none, and promptly send the patient to a hospital, than to miss this extremely dangerous pathology, or even more so to try to terminate the pregnancy in a day hospital at a antenatal clinic. The wrong tactics of a doctor can lead to death.

Oncological alertness

In the work of a antenatal clinic doctor, along with the above actions, oncological vigilance must be constantly present. The frequency of errors during mass preventive examinations is still high. However, it has been established that without the use of cytological examination such examinations are ineffective, because dysplasia and preclinical forms of cervical cancer are not visually detected.

The old and unshakable rule of thumb should always be kept in mind: all sorts of things bleeding from the genital tract not associated with pregnancy in a woman any age should be considered as cancer (!) until this diagnosis is reliably and reliably excluded. Ignoring this rather ominous, although very correct axiom, leads to a lot of trouble. Just like the well-known traffic rules, but, unfortunately, not always followed by drivers and pedestrians, the diagnostic and tactical postulates of gynecological oncology are “written in blood.” We should add to this premature deaths due to late diagnosis. In the figurative expression of E.E. Vishnevskaya, cancer “does not forgive” irresponsibility!

Long-term observation, hormonal examination, prescription of hemostatic drugs or even attempts at hormonal hemostasis for hyperplastic processes of the endometrium without the obligatory previous fractional therapeutic and diagnostic curettage with a thorough histological examination (which, unfortunately, is still often observed in the practice of some colleagues) are certainly rude tactical and diagnostic errors.

Among tumors of female genitalia ovarian cancer It ranks second in frequency after cervical cancer and first in the structure of gynecological mortality from cancer. The main reason for this is the extremely rapid, aggressive clinical course of the disease, manifested by an increase in the degree of malignancy of the tumor and the early onset of implantation, lymphogenous and hematogenous metastasis. The recognition of tumors at a late stage of their development is based on medical errors. It is they who give rise to the neglect of the process, which is observed in 44% of newly diagnosed patients.

For the diagnosis of malignant ovarian tumors, timely recognition of such a formidable symptom as the appearance of free fluid in the abdominal cavity is important. The presence of ascites more often indicates the advanced stage of the tumor process, although this symptom accompanies the development of some benign tumors of the uterine appendages, for example Meigs syndrome (ascites and hydrothorax) with ovarian fibroids. Gynecologists should be well aware of this so that patients with ascites are not mistakenly considered incurable, but promptly switch to a surgical method of treatment, which, after removing the tumor, leads to the rapid elimination of hydrothorax and ascites. It should be noted that even small ascites, the presence of which is sometimes very difficult to determine (especially in overweight patients), is easily diagnosed by ultrasound.

For early detection of patients with malignant neoplasms of the uterine appendages, a high risk group, which includes:

women with ovarian dysfunction and bleeding during menopause;
previously undergone surgical interventions for benign ovarian cysts with preservation of one of them, breast or stomach cancer;
those under observation for uterine fibroids;
suffering from chronic inflammatory processes of the uterine appendages and tubo-ovarian formations that are not amenable to conservative treatment;
patients with effusion in the serous cavities (abdominal, pleural);
women with primary functional ovarian failure;
patients with genital hypoplasia and a history of infertility.

As is known, uterine fibroids– one of the most common gynecological diseases. A deeper development of the issues of pathogenesis and the study of endocrine metabolic disorders confirm the need for maximum oncological vigilance to identify hyperplastic processes and malignant neoplasms of the endometrium in people with uterine fibroids. Uterine fibroids are often combined with atypical hyperplasia (7.6%), endometrial cancer (4%), uterine sarcoma (2.6%), benign (8.1%) and malignant (3%) ovarian tumors (Ya.V. Bohman, 1989).

Among the clinical symptoms of uterine fibroids, rapid tumor growth, recorded during clinical examination and ultrasound, as well as acyclic uterine bleeding, cause particular oncological suspicion. It is advisable to emphasize that the rapid growth of fibroids is considered to be an increase in its volume, which corresponds to 5 weeks of pregnancy per year.

Although the possible connection of uterine fibroids with hyperplastic processes and endometrial cancer has not been definitively established due to a certain commonality of their pathogenesis, it is necessary to actively identify precancerous diseases, cancer of the cervix and uterine body among patients registered at the dispensary for uterine fibroids, as well as timely detection indications for surgical treatment.

the size of the tumor exceeds the size of the uterus, corresponding to 12 weeks of pregnancy in young women and 15-16 in women after 45 years of age;
suspicion of malignant degeneration of the tumor for any size of the uterus;
its rapid growth (especially during menopause or menopause);
the presence of submucosal and subserous nodes on long stalks, prone to torsion and necrosis;
cervical localization of the tumor;
compression of adjacent organs by the tumor (the appearance of frequent urination, not associated with a urinary tract infection, disturbance of the act of defecation);
dysmenorrhea of the type of menorrhagia or metrorrhagia, accompanied by severe posthemorrhagic anemia.

Many diagnostic difficulties and, as a result, diagnostic errors cause malignant lesions of the vulva and vagina, despite the localization seemingly accessible to visual inspection. Vulvar cancer often develops against the background of degenerative processes such as kraurosis and leukoplakia. However, a true precancerous condition is dysplasia, which cannot be diagnosed without targeted biopsy and histological examination, which are not always performed. Long-term conservative treatment of patients with dystrophic diseases of the vulva without histological examination is a very common mistake and leads to delayed diagnosis. Prescribing ointments and creams with estrogens, corticosteroids and analgesics relieves pain and itching, and women, feeling relief, stop visiting the doctor. After 6-12 months, symptoms resume and a malignant tumor develops with metastases.

According to E.E. Vishnevskoy et al. (1994), long-term observation and symptomatic treatment of women with kraurosis and especially vulvar leukoplakia without the use of special research methods to exclude initial forms of cancer is the main cause of errors that determine the prevalence of the tumor process by the time the true disease is recognized.

It has been established that the diagnosis of such a seemingly easily accessible tumor as vaginal cancer, is also associated with a large number of errors, as a result of which more than 60% of diseases are detected only in stages II or III. In late diagnosis during gynecological examination, the widespread use of the Cusco double-leaf speculum plays a fatal role. As a result of its use, small tumors, especially those located in the middle and lower thirds of the vagina, being covered with a Cusco mirror, do not come into the field of view of the doctor or midwife in the examination room.

As practical experience shows, many defects and diagnostic errors are often associated with insufficient knowledge or failure to comply with some “secrets” of gynecological examination. It is not without reason that it is said: “He who researches well diagnoses well.” An important condition for the information content of any medical examination is the presence of sufficiently intense local lighting. A powerful light source allows for visual diagnostics to be carried out properly, rather than at a glance.

Fellow gynecologists often forget about the urgent need for a rectal examination, and in all cases without exception, and not just in virgins. Bimanual rectovaginal examination, somewhat forgotten by many practitioners, is very useful. His technique is quite simple: after a routine vaginal examination, the index finger is placed in the vagina and a well-lubricated middle finger is placed in the rectum. This makes it much easier to palpate the retroflexed uterus, uterosacral ligaments and rectovaginal septum for mass formations, for example in retrocervical endometriosis.

Diagnosis of infectious and inflammatory diseases

Many errors occur in the diagnosis and treatment of infectious and inflammatory diseases of the genitals. Having received the result of a routine examination, informing about the detection of, for example, trichomonas or fungi of the genus Candida, the doctor prescribes a certain specific treatment and even often notes some positive results. Unfortunately, a complete cure does not always occur, since chlamydia, mycouraplasmosis and other urogenital infections often remain “behind the scenes,” the reliable diagnosis of which is impossible only through conventional bacterioscopy of smears.

However, even when sufficiently reliable laboratory results are obtained to determine the type of urogenital infection, drug treatment is not always prescribed correctly and adequately. For example, in case of urogenital chlamydia and mycoplasmosis, it is advisable and effective to use antibacterial drugs of only three pharmacological groups: tetracyclines, macrolides and fluoroquinolones. Reliable and well-tested sulfonamides, even in combination with trimethoprim (Biseptol), due to their low effectiveness in gynecological pathology, are currently of only historical interest. Often, when treating various urogenital infections, they forget that patients almost always have a concomitant anaerobic flora, and therefore the simultaneous use of drugs of the imidazole group (metronidazole, tinidazole, ornidazole, etc.) is indicated.

With regard to drug dosing, two extremes are often observed: unreasonably exceeding the permissible limits or prescribing unjustifiably low doses. For example, the prescription of doxycycline at a dose of 100 mg once a day for 5 days, acceptable for the treatment of acute bronchitis, is completely insufficient for the treatment of acute salpingoophoritis; The WHO recommended dose is 100 mg 2 times a day for at least 10 days.

Recently, it has become fashionable for some medical specialists to become interested in new (or well-forgotten old) pharmacotherapeutic methods of alternative medicine. This is, first of all, homeopathy, antihomotoxic therapy, prescription of dietary supplements, etc. Without underestimating the possible certain effectiveness of these methods, it should be said that they in no way replace appropriate antibacterial therapy, the refusal of which (in favor of natural remedies) is sometimes fraught with severe septic complications.

The use of hormonal drugs, in particular combined oral contraceptives (COCs), is far from simple and quite responsible. When so-called breakthrough bleeding occurs while taking COCs, some doctors, instead of the necessary short-term increase in their doses (until the bleeding stops), often prescribe hemostatic therapy such as Vikasol and calcium chloride, and COCs are completely unreasonably canceled, which is a gross mistake. As a result, increased bleeding occurs.

COCs are also widely used for the treatment of various gynecological diseases (endometriosis, polycystic ovary syndrome, uterine fibroids, etc.). However, this applies only to monophasic COCs, because three-phase ones are absolutely not suitable for medicinal purposes. They do not completely suppress folliculogenesis, so they can contribute to the progression (!) of the pathological process in the above diseases. In particular, with the use of three-phase COCs, glandular regression of the endometrium is not observed, which is contraindicated in its hyperplastic processes (I.V. Lakhno, 2002).

Antiestrogens (clomiphene, clostilbegit, tamoxifen) are often used to stimulate ovulation. It is extremely necessary to carefully (preferably daily) monitor the size of the ovaries (vaginal examination or ultrasound), because in some cases there are phenomena of hyperstimulation, sometimes accompanied by apoplexy.

When prescribing drug therapy, possible chemical and pharmacological incompatibility of individual drugs (for example, calcium and magnesium are antagonists), allergic history, the presence of extragenital pathology, and other significant factors are not always taken into account. This can contribute to the development of complications, because, unfortunately, “Graviora quedam sunt remedia periculis” (“Some medicines are worse than the disease” - lat.).

No equipment can replace the highly qualified and creative thoughts of a doctor. Against the backdrop of a significant number of errors, from which not a single system of training specialists and not a single healthcare system in the world is immune, this problem should be given much more attention.

OBSTETRICS AND GYNECOLOGY, 2007, No. 5
V. E. RADZINSKY, I. N. KOSTIN

SAFE MISTRY
Department of Obstetrics and Gynecology with a course of perinatology (head - Prof. V. E. Radzinsky) Peoples' Friendship University of Russia, Committee on the Quality of Medical Care of the Russian
Society of Obstetricians and Gynecologists, Moscow

“Safe obstetrics” is a term that naturally replaces the expression safe motherhood. If in the last third of the last century the world community made efforts to unite humanitarian organizations, sociologists, educators, and doctors in the fight for a woman’s right not to die for reasons related to pregnancy and childbirth, then already in 1995 at the World Congress on Maternal Mortality there was not a single official representative of the UN, WHO, UNICEF or other international organizations. There are at least two reasons for this. It turned out that to transfer so-called home births to hospital births requires huge financial costs (up to 72 trillion US dollars). In addition, by the end of the 20th century, it became obvious that the WHO program (1970) to reduce maternal mortality by 2 times was not only not implemented, but by 2000 the situation had even worsened: instead of 500 thousand women dying annually due to pregnancy and childbirth, there were 590 thousand of them. There are many reasons for this, in particular, the priority of family planning turned out to be unrealized. However, the main reason is a change in attitude towards the family problem - it has been placed under the jurisdiction of national administrations. The consequences of this were not slow to be felt: there were significantly fewer program reports on the problems of maternal mortality at the last FIGO congresses (2003, 2006), and there was practically no unified interdisciplinary strategy at all.
The determination of maternal mortality by average annual per capita income (API) has long been proven. Thus, in Uganda the MDI is US$100, the maternal mortality rate is 1100 per

100,000 live births; in Egypt, the SOP is $400, maternal mortality is 100. Thus, the natural way to reduce maternal mortality is to increase the welfare of the state. This also applies to countries where there is no state system for the protection of motherhood and childhood.
Statistics show that more than half a million women around the world die every year without fulfilling the function intended by nature - reproduction. It should be noted that every tenth case of maternal mortality is, to one degree or another, a consequence of medical errors. It is medical errors (real or imaginary) that become a real danger for a doctor, who is subject not only to legal prosecution and sanctions from insurance companies, but also to “pressure” from society.
In general, the number of lawsuits against doctors has increased more than 5 times over the past 4 years. In this regard, two facts are interesting. First, there were no counterclaims from obstetricians-gynecologists against the plaintiffs at all. The second - in an anonymous survey of gynecologists in the Moscow region (A.L. Gridchik, 2000) to the question: how often were you a direct or indirect culprit of maternal mortality, the doctors answered very differently depending on their work experience. 15% of doctors with up to 15 years of experience, 43% with 16-25% years of experience, and 50% with more than 25 years of experience considered themselves guilty.
It is known that there are different types of medical errors. Firstly, these are gross violations of generally recognized norms, rules, protocols due to

low professional knowledge of medical personnel. Secondly, “strict” compliance with the same generally accepted norms, rules, protocols, etc. The situation is paradoxical.
Like any science, obstetrics is a dynamically developing discipline that constantly absorbs all the latest achievements of medical science and practice. This is typical for any scientific field, but it must be borne in mind that pregnancy and childbirth are a physiological process, and not a set of diagnoses. Therefore, any intervention in this area should be undertaken only as a last resort. However, in recent decades there has been a large information boom, which is manifested by the emergence of contradictory theories, ideas, and proposals for the management of pregnancy and childbirth. Under these conditions, it is difficult, and sometimes impossible, for practical doctors to understand the expediency and benefits of some provisions or, on the contrary, the risk for the mother and fetus of others: what is the effectiveness of certain methods of managing pregnancy and childbirth, what is the degree of their aggressiveness for the mother and fetus, how they affect the child’s health in the future.
At the present stage of development of obstetrics, there is a number of erroneous, scientifically unsubstantiated ideas and approaches, the consequences of which in most cases can be characterized as manifestations of “obstetric aggression”. The latter sometimes becomes the “norm” for pregnancy and childbirth, unfortunately, not always with a favorable outcome. As an example, I would like to cite data from the Netherlands: the frequency of use of oxytocin during childbirth by doctors is 5 times higher than when childbirth is managed by nursing staff, and the frequency of caesarean sections is 3 times higher in medical hospitals.
In Russia, against the background of the most acute problem of population reproduction, in 2005 more than 400 women died from causes related to pregnancy and childbirth. The dynamics of the maternal mortality rate in the Russian Federation over the past decade inspires cautious optimism. As for the structure of the causes of maternal mortality, it fully corresponds to the global one, which is 95% “provided” by the countries of Africa and Asia (bleedings, abortions - 70%, sepsis, gestosis).
The reasons for such unfavorable outcomes of pregnancy and childbirth for the mother and fetus are, to a large extent, the so-called obstetric aggression.
Obstetric aggression is iatrogenic, scientifically unsubstantiated actions, supposedly aimed at benefit, but as a result bringing only harm to the mother and fetus. This leads to an increase in complications of pregnancy and childbirth, an increase in perinatal mortality, infant and maternal morbidity and mortality. In this regard, a natural question arises about the so-called safe obstetrics.
Safe obstetrics is a set of scientifically proven approaches based on the achievements of modern science and practice.

The overall goal of safe obstetrics is primarily to reduce maternal and perinatal morbidity and mortality. However, this provision is currently insufficient.
In recent decades, revolutionary changes have occurred in all spheres of life in our society. Modern socio-economic conditions put forward new requirements for the organization of healthcare. At the same time, such an indicator as the quality of services provided becomes one of the most important factors determining the activities of any healthcare institution.
The formation and development of the health insurance system and market relations also changed the social behavior of patients and contributed to the establishment of social control over the quality of medical services.
Therefore, the most important feature of modern healthcare is the strengthening of trends in the legal regulation of medical activities. One of the directions of legal reform in healthcare should be the determination of measures of responsibility for non-compliance or formal implementation of legislation for all healthcare authorities involved in ensuring the constitutional right of citizens to receive appropriate medical care, and in relation to a citizen doctor - ensuring his constitutional rights and professional activities, including liability insurance.
The risk of adverse outcomes of pregnancy and childbirth or the development of legal conflicts accompanies the “interested parties” - the doctor and the patient - from the first days of pregnancy, and sometimes extends to the period of pre-conception preparation.
Unobtrusive “aggression” often begins with the very first appearance of a pregnant woman at the antenatal clinic. This applies to unnecessary, sometimes expensive, research and analysis, as well as treatment. The prescription of a standard complex of drugs (vitamin and mineral complexes, dietary supplements, etc.) often replaces pathogenetically based therapy. For example, in case of threatening early termination of pregnancy, in all cases, without appropriate examination, progesterone drugs, ginipral and others are prescribed, which costs over half a billion rubles.
Separately, it should be said about the biotope of the vagina - the most unprotected area of the reproductive system from medical actions. It has become common practice for doctors to identify the presence of any type of infection in the vaginal contents, while prescribing inadequate treatment (disinfectants, powerful antibiotics without determining sensitivity to them, etc.). No less a mistake is the desire to restore vaginal eubiosis. As is known, “nature abhors a vacuum,” therefore, after antibacterial therapy, the microbiological niche is quickly populated by the same microorganisms that, at best, were the target of treatment (staphylococci, streptococci,

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cocci, Escherichia coli, fungi, etc.), but with a different antibacterial resistance.
High-quality PCR gives a lot of incorrect information, forcing the doctor to make certain “aggressive” decisions. Therefore, in the USA this research is carried out 6 times less often than in the Russian Federation, for the reason that it is “too expensive and overly informative.” In order to get rid of the desire to “treat tests,” since 2007 in the United States, even conducting bacterioscopic examinations of pregnant women without complaints was prohibited.
The study of the evolution of the composition of the biotope of the genital tract over the past decades gives the following results: in every second healthy woman of reproductive age, gardnerella and candida can be identified in the vaginal contents, in every fourth - E. coli, in every fifth - mycoplasma. If the CFU of these pathogens does not exceed 105, and the CFU of lactobacilli is more than 107 and there are no clinical manifestations of inflammation, then the woman is considered healthy and does not need any treatment. High-quality PCR does not provide this important information. It is informative only when detecting microorganisms that should practically be absent from the vagina (treponema pallidum, gonococci, chlamydia, trichomonas, etc.).
Another manifestation of so-called obstetric aggression in antenatal clinics is the unreasonably widespread use of additional research methods. We are talking about numerous ultrasound examinations, CTG in the presence of a physiological pregnancy. Thus, prenatal diagnostic methods should be used not to find something, but to confirm the assumptions that have arisen about the risk of developing perinatal pathology.
What is the way out of this situation? Risk strategy - identifying groups of women whose pregnancy and childbirth may be complicated by disruption of the vital functions of the fetus, obstetric or extragenital pathology. These risks must be assessed in terms of significance not only throughout pregnancy, but, very importantly, during childbirth ("intrapartum gain"). Many births that had unfavorable outcomes for both the mother and the fetus are based on underestimation or ignorance of intrapartum risk factors (pathological preliminary period, meconium fluid, labor anomalies, etc.).
The tactics of managing pregnant women at the end of the third trimester of pregnancy also requires revision: unreasonable hospitalization in sometimes extremely overloaded departments of pathology of pregnant women. In particular, this applies to dropsy in pregnancy. According to modern concepts, normal weight gain in pregnant women fluctuates in a fairly wide range (from 5 to 18 kg) and is inversely proportional to the initial body weight.
The majority (80%) of pregnant women in need of treatment can successfully use the services of a day hospital, saving material and

financial resources for the maternity hospital, and without separating the woman from her family.
A pregnant woman hospitalized in pregnancy pathology departments without convincing reasons at the end of pregnancy has one way - to the maternity ward. It is believed that in this pregnant woman, using various methods, first of all, the cervix should be prepared. This is followed by amniotomy and labor induction. It should be noted that amniotomy in the department of pathology of pregnant women is performed in more than half of the patients and is not always justified. This includes amniotomy when the cervix is not mature enough, under the pressure of a diagnosis (dropsy, at best - gestosis, doubtful post-maturity, placental insufficiency with a fetal weight of 3 kg or more, etc.). It should be emphasized that amniotomy for an “immature” cervix significantly increases the incidence of complications during childbirth and cesarean section. Expert estimates show that every fourth caesarean section is the result of obstetric aggression.
The introduction of elements of new perinatal technologies does not find proper understanding: an excess of sterilizing measures (shaving, the use of disinfectants in practically healthy pregnant women) does not leave a chance for any biotope (pubic, perineal, vaginal) to perform its protective functions during childbirth and the postpartum period.
It is impossible to ignore the supposedly resolved, but at the same time eternal question - how long on average childbirth should last. This is a strategic question, and therefore incorrect answers to it entail a chain of incorrect actions.
According to the literature, the duration of labor for first- and multiparous women at the end of the 19th century averaged 20 and 12 hours, respectively, and by the end of the 20th century - 13 and 7 hours. Analyzing the time parameters of this value, we can assume that on average each decade the duration labor in primiparous women decreased by almost 1 hour, in multiparous women - by 40 minutes. What has changed during this time? Genetically determined, centuries-old physiological process of childbirth? Hardly. Anthropometric indicators of the female body, in particular the birth canal? No. A natural process of development of scientific thought? Without a doubt! Of course, most achievements in obstetric science and practice have a noble goal - reducing perinatal mortality, maternal morbidity and mortality. But an analysis of the current state of obstetrics shows that we often drive ourselves into a dead end. Why are the world averages for the duration of labor the starting point for making, most often hasty and in most cases, wrong decisions in a particular pregnant woman (the frequency of use of uterotonic drugs in the world reaches 60%, and this is only the data taken into account). Time, and not the dynamics of the birth process, became the criterion for the correct course of labor. Conducted studies indicate that women who begin labor in a maternity institution

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nii have a shorter duration of labor compared to those who present in the middle of the first stage of labor. It should be noted that in the 1st group of women in labor, more difficult births are recorded, characterized by a large number of various interventions and a higher frequency of cesarean sections. No one knows the true figures for the use of prohibited benefits during childbirth (Kristeller’s method, etc.).
An assessment of the obstetric situation using the Kristeller manual was described by E. Bumm in 1917. E. Bumm emphasized that this method is the most aggressive and dangerous intervention in childbirth.
Currently, at the proposal of the French Association of Obstetricians and Gynecologists, the European Union is considering the issue of depriving a doctor of the right to practice obstetrics in all countries of the community if he declares the use of the Christeller benefit. Presented at the last World Congress of Obstetricians and Gynecologists (FIGO, 2006), this initiative was warmly welcomed by delegates.
A retrospective analysis of births that resulted in injuries to newborns, their resuscitation, including mechanical ventilation, revealed the main mistake: the use of the Kristeller method instead of surgical delivery that was not carried out on time.
Issues of providing obstetric care using episiotomy require strict restrictive frameworks. The desire to reduce the length of the incision leads to the exact opposite result: up to 80% of so-called small episiotomies turn into banal perineal tears. Therefore, instead of stitching up a cut wound, you have to stitch up a laceration. As a result, incompetence of the pelvic floor muscles occurs in young women. It has been established that episiotomy during fetal hypoxia is not a radical method of accelerating labor, and if the head is high, this operation does not make sense at all. Therefore, the growing number of cases of pelvic floor muscle failure is a consequence not only of poor restoration of the perineum, but also of the so-called sparing, and often unnecessary, dissection.
As you know, the leading cause of maternal mortality in Russia, as well as in the world, is obstetric hemorrhage. There are still ongoing discussions about the quantity and quality of infusion therapy when replenishing blood loss in obstetrics. Old views on this issue are now being critically assessed. Now there is no doubt that the priority of infusion therapy is the high-quality composition of transfused solutions. This is especially true for infusion therapy in women with gestosis, in which overhydration can lead to dire consequences. And refusal from such “aggressive” infusion media as gelatinol, hemodez, reopolyglucin, etc. significantly reduces the occurrence of disseminated intravascular coagulation syndrome. Hydroxyethyl starch, 0.9% sodium chloride solution, frozen plasma should be the main infusion media.

But this is only part of the problem of successfully treating obstetric hemorrhage. The main points should include a correct assessment of the quantitative (volume) and qualitative (disturbance of the coagulation system) components of blood loss, timely and adequate infusion-transfusion therapy, timely and adequate surgical treatment (organ-preserving tactics) and constant instrumental and laboratory monitoring of vital functions and homeostasis.
The main causes of mortality in massive obstetric hemorrhages are violation of the above points (delayed inadequate hemostasis, incorrect infusion therapy tactics, violation of the phasing of care).
Oddly enough, even such a trivial thing as assessing the volume of blood loss can play a decisive role in the outcome of the treatment of the bleeding itself. Unfortunately, the assessment of blood loss is almost always subjective.
Timely treatment of hypotonic bleeding using all necessary components allows you to successfully cope with the situation already at the conservative stage of obstetric care. A prerequisite is timely diagnosis of bleeding. Many legal cases brought regarding maternal deaths relate to this point. Then a thorough assessment of the volume of blood loss and calculation of the infusion-transfusion therapy program (depending on the woman’s body weight) and its correction during treatment are necessary. Of great importance is multicomponent treatment, which involves invasive intervention (manual examination of the walls of the uterus or bimanual compression - forgotten methods of Snegirev and Sokolov), the use of a system for intravenous administration of solutions, the introduction of uterotonics, monitoring hemodynamic and hemostasiological parameters and, importantly, constant assessment of blood loss ( during treatment).
Recently, an intrauterine hemostatic balloon has been widely used to stop hypotonic bleeding. This method cannot be called new, since the first mention of the use of this kind of means dates back to the middle of the 19th century (1855). However, the use of modern materials and solutions has made it possible to once again turn to this method. Its effectiveness is 82%.
The next factor that often leads to dismal birth outcomes is the decision to switch from the conservative to the surgical stage of treatment of obstetric hemorrhage. To a greater extent, it concerns the psychology of the doctor: by any means to delay laparotomy and removal of the uterus. When 3,067 uteruses were promptly removed during childbirth in the Russian Federation in 2001, the number of lawsuits in the country regarding deprivation of the reproductive organ exceeded that for cases of maternal mortality. It shouldn't be this way. What options are there to stop bleeding during surgery?

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The sequence of actions is as follows:
- injection of prostenon into the uterine muscle;
- ischemia of the uterus by applying clamps and ligatures to the vascular bundles;
- application of hemostatic compression sutures B-Lynch and Pereira;
- ligation of the iliac arteries;
- angiographic embolization;
- and only then amputation or extirpation of the uterus.
The tactics for treating obstetric hemorrhage should always be based on the organ-preserving principle. It is unnatural if a woman admitted to a maternity hospital is discharged without a reproductive organ. Of course, there are exceptions to the rule, but today there is no doubt that organ-preserving tactics should become a priority in the treatment of obstetric hemorrhage.
Another cause of death in the Russian Federation is abortion, or rather its complications. Despite the decline in the absolute number of abortions over the past decade, they occupy 2nd place in the structure of causes of maternal mortality in Russia. There are reasons for this. Unfortunately, under the influence of socio-economic factors, abortion in the Russian Federation remains the main method of birth control (the frequency of use of highly effective methods of contraception in the Russian Federation is 3 times lower than in economically developed countries; in addition, more abortions are performed in Russia than in European countries) .
To illustrate the complexity of the relationship between legislative decisions and the reaction of society, I would like to give an example of an ill-conceived decision to abolish a larger number (9 out of 13) of social indications for late termination of pregnancy, after which the number of criminal abortions increased by 30% (!), and not all of them ended well. Banning abortions without offering anything in return is pointless; a comprehensive solution to the problem is necessary.
Until now, the mystery of obstetrics is gestosis. Modern scientific research has seemingly approached the last barrier in the pathogenetic chain of this pregnancy complication - genetics, but there is still no complete picture of the development of preeclampsia. The price of ignorance is the lives of thousands of women dying around the world, including in Russia. Strange as it may seem, gestosis is probably the most easily controlled cause of maternal mortality. The question is timely diagnosis and adequate treatment. Of course, we are talking about treatment conditionally - the only successful method of treating this complication is

The only way to prevent pregnancy is to terminate it in a timely manner. The main task is to prevent the occurrence of eclampsia, from which pregnant women actually die. The gold standard of treatment is oncoosmotherapy, therapy in accordance with the severity of the disease and delivery according to indications. But questions remain: how to determine the severity of gestosis, how long to treat, what method of delivery, etc. The correct solution to these issues is the safety of the patient and the doctor.
The fight against maternal mortality remains and, of course, will remain a priority in the work of the obstetric service, however, the formation and development of the health insurance system and market relations in the country have changed the social behavior and mentality of patients. Their awareness of modern methods of obstetric care, paradoxically, sometimes embarrasses some doctors who do not bother to educate themselves. We are talking about modern perinatal technologies - a set of measures based on evidence-based medicine. Not introducing them where possible is, to put it mildly, short-sighted, and in some situations even criminal (outbreaks of infectious diseases). The worse the sanitary and technical condition of an obstetric hospital, the more it needs the mother and child to stay together, exclusively breastfed, early discharge. Theoretically, everyone knows this; in practice, reluctance to change something gives rise to a pile of misconceptions.
We have already said above that every tenth case of maternal death in the world is due to the fault of a doctor. How can we protect the patient, as well as the doctor himself, from the consequences of incompetent actions? The cheapest but extremely effective way is to develop appropriate standards and protocols. In the modern information world, it is no longer possible to work without this. First of all, we are talking about protocols for the treatment of obstetric hemorrhage, management of pregnant women with gestosis, with prenatal rupture of amniotic fluid, management of childbirth in the presence of a uterine scar, etc., in the future - for each obstetric situation.
In conclusion, it should be noted that this report covers only a small number of current issues and problems of obstetric practice that are in dire need of solution, revision and critical evaluation. Further research into this acute problem will significantly improve the most important indicators of the obstetric service as a whole.

« Quod ribi fieri non vis, alteri ne faceris"
(“What you don’t wish for yourself, don’t do to someone else,” lat.)

Despite the well-known sacramental statement “Errare humanum est” (“To err is human”, Latin), the mistakes of medical personnel are very negatively perceived by the objects of our professional aspirations (patients), as well as by higher authorities. And the culprits (physicians of all specialties and ranks) add a lot of worries and gray hair...

Objective circumstances leading to an error include conditions under which it is not possible to conduct a particular study. It is also necessary to note the inconsistency of individual postulates and principles in the field of theoretical and practical medicine; In this regard, views on the etiology, pathogenesis, and understanding of the essence of many diseases change from time to time. In each individual case, the question of classifying a doctor’s actions as an error, especially when differentiating between ignorance due to insufficient qualifications and elementary medical ignorance, is decided based on the specific features of the course of the disease, duration of observation, examination opportunities, etc.

It is incorrect to always associate the subjective causes of diagnostic and tactical errors only with the qualifications of doctors. Undoubtedly, it is difficult to overestimate the importance of knowledge for correct diagnosis. But knowledge is not just the preparation of a doctor, it is also the ability to accumulate, understand, and use it, largely depending on the individual abilities, intelligence, character traits and even temperament of a particular specialist. “Life does not fit into narrow frameworks, doctrines, and its changeable casuistry cannot be expressed by any dogmatic formulas” (N. I. Pirogov).

Taking into account the specifics of obstetric and gynecological practice, in particular outpatient practice, as well as the fact that “Ignoti nulla curatio morbi” (“You cannot treat an unrecognized disease,” Lat.), we have made an attempt to classify and consider the most “typical” errors.

A considerable number of them are associated with pregnancy diagnosis . The use of modern highly sensitive tests in combination with an ultrasound examination (preferably carried out by a qualified obstetrician-gynecologist, and not a “wide-profile ultrasound diagnostic specialist”) allows us to avoid gross errors. For example, a positive hCG urine test with an “empty” uterine cavity dictates the urgent need for urgent hospitalization of a patient with a well-founded suspicion of an ectopic pregnancy.

A form of ectopic pregnancy called cervical pregnancy , is quite rare, but very dangerous. Usually in the early stages it is accompanied by bleeding, which is associated with the destructive effect of chorion on the vessels of the cervix. The appearance of spotting or bleeding is mistakenly regarded by the doctor as an interruption of a normal intrauterine pregnancy, and only barrel-shaped cervix may serve as a sign of cervical localization of the fertilized egg. However, such changes in the cervix are sometimes considered as a manifestation of an incipient abortion, when the fertilized egg, upon being born, descends into the lumen of the distended cervical canal with an unopened external os. Indeed, in such cases the neck may also have a barrel shape. The existing hypertrophy of the cervix, as well as uterine fibroids in combination with pregnancy, greatly complicates the differential diagnosis. It is much better to suspect a cervical pregnancy where there is none and promptly send the patient to a hospital than to miss this extremely dangerous pathology or, even more so, to try to terminate the pregnancy in a day hospital at a antenatal clinic. The wrong tactics of the doctor can lead to the death of the patient.

In the work of an obstetrician-gynecologist, along with the so-called “gravid alertness” (see above), it is constantly urgently necessary cancer alertness . The frequency of errors during mass preventive examinations is still high. It has been established that without the use of cytological examination they are ineffective, since dysplasia and preclinical forms of cervical cancer are not detected visually, that is, with the naked eye.

The old and unshakable rule of thumb should always be kept in mind: any bleeding from the genital tract not associated with pregnancy in a woman any age should be considered as cancer (!) until this diagnosis is reliably and reliably excluded. Ignoring this rather ominous, although very correct axiom, leads to a lot of trouble. Just like the well-known traffic rules, but, unfortunately, not always followed by drivers and pedestrians, the diagnostic and tactical postulates of gynecological oncology are “written in blood.” In the figurative expression of E. E. Vishnevskaya (1994), “cancer “does not forgive” irresponsibility”! Long-term observation, hormonal examination, prescription of hemostatic drugs or even attempts at hormonal hemostasis, for example, in case of hyperplastic processes of the endometrium without the obligatory previous fractional therapeutic and diagnostic curettage with a thorough histological examination, which is still, unfortunately, sometimes observed in the practice of some colleagues - of course , are gross tactical and diagnostic errors.

Among tumors of female genitalia ovarian cancer It ranks second in frequency after cervical cancer, and first in mortality from gynecological cancer. The main reason is the extremely rapid, aggressive clinical course, manifested by an increase in the degree of malignancy of the tumor and the early onset of implantation, lymphogenous and hematogenous metastasis. The recognition of late-stage tumors is often based on medical errors; It is they who give rise to the neglect of the process, which is noted in 44% of newly diagnosed patients.

Timely recognition of such a formidable symptom as the appearance of free fluid in the abdominal cavity is important for the diagnosis of malignant ovarian tumors. The presence of ascites more often indicates the neglect of the tumor process, although this symptom accompanies the development of some benign tumors of the uterine appendages. For example, Meigs syndrome (ascites and hydrothorax) with ovarian fibroma. Gynecologists should know this well, so that patients with ascites are not mistakenly considered incurable, but promptly resort to a surgical method of treatment, which, after removing the tumor, leads to the rapid elimination of hydrothorax and ascites. By the way, even small ascites, the presence of which is sometimes very difficult to determine by conventional methods, especially in obese patients, is easily diagnosed with ultrasound.

As is known, uterine fibroids- one of the most common gynecological diseases. In-depth development of issues of pathogenesis and the study of endocrine and metabolic disorders confirm the need for maximum oncological vigilance to identify hyperplastic processes and malignant neoplasms of the endometrium in patients with uterine fibroids, which are often combined with atypical hyperplasia (7.6%), endometrial cancer (4%), sarcoma uterus (2.6%), benign (8.1%) and malignant (3%) ovarian tumors (Ya. V. Bokhman, 1989). Among the clinical symptoms of uterine fibroids, rapid tumor growth, recorded during clinical and ultrasound examinations, and acyclic uterine bleeding cause particular oncological suspicion. It is advisable to emphasize that “rapid growth” is considered to be an increase in the tumor per year by an amount corresponding to 5 weeks or more of pregnancy. It is necessary to actively identify precancerous diseases, cancer of the cervix and uterine body among patients registered at the dispensary for uterine fibroids, as well as timely determination of indications for surgical treatment.

Many diagnostic difficulties and, as a result, diagnostic errors cause malignant lesions vulva and vagina, despite the localization seemingly accessible to visual inspection. Vulvar cancer often develops against the background of degenerative processes, such as kraurosis and leukoplakia. However, a true precancer is dysplasia, which cannot be diagnosed without targeted biopsy and histological examination, which is not always done. Long-term conservative treatment of patients with dystrophic diseases of the vulva without histological examination is a very common mistake and leads to delayed diagnosis. Prescribing ointments and creams with estrogens, corticosteroids and analgesics relieves pain and itching and, feeling relief, patients stop visiting the doctor. 6-12 months pass, the symptoms resume, and a malignant tumor develops with metastases.

Diagnosis of such a seemingly easily accessible tumor as vaginal cancer, is still associated with a large number of errors, as a result of which more than 60% of patients are detected in stages II and III of the disease. The widespread use of the Cusco bicuspid speculum during gynecological examination plays a fatal role in late diagnosis. As a result of this, small tumors, especially those located in the middle and lower thirds of the vagina, being covered with a Cusco mirror, do not come into the field of view of the doctor (or midwife in the examination room).

As practical experience shows, many defects and diagnostic errors are often associated with insufficient knowledge or failure to comply with “some “secrets” of gynecological examination” (Mayorov M.V., 2005). It is not for nothing that it is said: “He who researches well diagnoses well.” An important condition for the information content of any medical examination is the presence of sufficiently intense local lighting. A powerful, directional light source allows visual diagnosis to be carried out properly, rather than at a glance.

Colleagues - gynecologists often forget about the urgent need for a rectal examination, and in all cases without exception, and not just in virgins. Bimanual recto-vaginal examination, somewhat forgotten by many practitioners, is very useful. His technique is quite simple: after a routine vaginal examination, the index finger is placed in the vagina, and a well-lubricated middle finger is placed in the rectum. In this way, it is much easier to palpate the uterus in a state of retroflexion, the uterosacral ligaments and the recto-vaginal septum, in particular, to determine space-occupying formations, for example, in retrocervical endometriosis.

Many errors occur in the diagnosis and treatment of infectious and inflammatory diseases of the genitals. Having received the result of a routine test informing that the patient has, say, trichomonas or fungi of the genus Candida, the doctor prescribes a certain specific treatment and often even notes some positive results (“It has become much easier!” the patient happily reports).

However, a complete cure does not always occur, since chlamydia, myco-ureaplasmosis and other urogenital infections often remain “behind the scenes”, reliable diagnosis of which is not possible only through conventional bacterioscopy of smears. But even when sufficiently reliable laboratory results are obtained to determine the type of urogenital infection, drug treatment is not always prescribed correctly and adequately. For example, in case of urogenital chlamydia and mycoplasmosis, it is advisable and effective to use antibacterial drugs of only three pharmacological groups: tetracyclines, macrolides and fluoroquinolones (Mayorov M.V., 2004). “Reliable and well-tested” sulfonamides, even in combination with trimethoprim (Biseptol), due to their low effectiveness in gynecological pathology, are currently only of historical interest. Often, when treating various urogenital infections, they forget that patients almost always have a concomitant anaerobic flora, and therefore the simultaneous use of drugs of the imidazole group (metronidazole, tinidazole, ornidazole, etc.) is indicated.

With regard to dosage, two extremes are observed: unreasonably exceeding the permissible ones or, conversely, prescribing unjustifiably low doses. For example, the prescription of doxycycline at a dose of 100 mg once a day for 5 days, acceptable for the treatment of, say, acute bronchitis, is completely insufficient for the treatment of acute salpingoophoritis; The WHO recommended dose is 100 mg 2 times a day for at least 10 days.

The use of hormonal drugs, in particular combined oral contraceptives (COCs), is far from simple and quite responsible. When so-called “breakthrough” bleeding often occurs while taking COCs, some doctors, instead of the necessary short-term increase in their dosage (until the bleeding stops), prescribe hemostatic therapy such as Vikasol and calcium chloride, and COCs are completely unreasonably canceled, which is a gross mistake. As a result, there is increased bleeding.

Combined oral contraceptives are widely used for the treatment of various gynecological diseases (endometriosis, polycystic ovary syndrome, uterine fibroids, etc.). But this applies only to monophasic COCs, since triphasic COCs are absolutely not suitable for therapeutic purposes. They do not completely suppress folliculogenesis, so they can contribute to the progression (!) of the pathological process in the above diseases. In particular, against the background of the use of three-phase COCs, glandular regression of the endometrium is not observed, which is contraindicated in its hyperplastic processes (Lakhno I.V., 2002).

Antiestrogens (clomiphene, clostilbegit, tamoxifen) are often used to stimulate ovulation. Careful (preferably daily) monitoring of the size of the ovaries (vaginal examination or ultrasound) is imperative, because, in some cases, hyperstimulation phenomena are observed, sometimes fraught with apoplexy.

No machine can replace good training and creative thought of a doctor. Against the backdrop of a significant number of errors, from which not a single system of training doctors and not a single healthcare system in the world is guaranteed, this problem should be given much more attention. Even the ancient Romans quite rightly stated: « Bene facit, qui ex aliorum erriribus sibi exemplum sumit" (“He who learns from the mistakes of others does well,” Latin)

Statistics indicate an increase in medico-legal cases and also indicate significant interest in medico-legal trials by the press and the public.
At the same time, the facts of not only the large increase in cases, but also the large percentage of dismissals and acquittals in forensic cases deserve attention.
The positive aspects of this increase in the initiation of forensic cases include: 1) raising legal awareness and developing the activity of broad layers of workers, 2) confidence in the great attention of the court to the needs and interests of workers. The negative aspects are: 1) the population lacks basic concepts of medicine, 2) belief in the omnipotence of medicine, 3) unfamiliarity with the limits of medical knowledge. Forensic medical practice in this direction indicates a number of cases of insufficiently justified prosecution of medical workers for criminal liability. It goes without saying that the interests of health care require conditions in which medical workers would be able to work confidently without fear of being held criminally liable for the unfortunate outcome of medical interventions in cases where there is no intentional or careless crime on their part. On the other hand, in forensic medical practice, although in a limited number, there are cases in which elements of consciousness, or rather intent, are mixed into the negative action of a doctor, which entailed some kind of harm to the patient’s body. Such actions, as well as dishonesty and gross negligence of a doctor, of course, should be considered criminal offenses. Such criminals or consciously dishonest persons include persons whose activities are socially dangerous in nature, and, according to Abuladze, every amateur practitioner should be classified as such. Such persons, who dare to pose as specialists in one or another branch of medical disciplines and armed with only an insignificant amount of knowledge, must inevitably cause a lot of harm to those who entrust their health to them and seek from them correct and specialized medical care. The sad consequences for patients, as a product of the activities of such “false specialist doctors,” as Lik calls them, must, of course, be taken into account as far from accidental misfortunes (accidental misfortunes, unfortunately, are always possible when healing even with the most conscientious doctors). Such actions cannot be equated with actions fatal to the patient, which are sometimes blamed on the so-called “encyclopedists” practitioners. These doctors may sometimes be faced with the extreme necessity of showing a special medical benefit that they are unable to perform properly in accordance with the level of their insufficient knowledge and experience.
Forensic medical practice shows that actions and deeds for which doctors are brought to justice in the course of their professional activities can be divided into three groups. The first group, which provides the most abundant forensic material, can include such very diverse cases where the doctor is accused of some facts from his professional activity that led to death or the final result of healing that is difficult for the body. This group embraces surgical and obstetric cases, the latter being particularly predominant. This is due to numerous abuses of the right and conditions for induced abortion.
The second group consists of cases of charges brought against a doctor for failure to provide medical care that could have prevented certain consequences that caused the death of the patient or damage to her health.
The third group includes very rare cases when a doctor is held criminally liable for concealing some fact that became known to him from the patient he was treating and for which the relevant persons should have been brought to justice. The first two groups concern cases of deliberate violation by a doctor of his direct duties. However, in the second group, the life situation shows that in a number of cases, refusal of medical care, which entailed sad consequences for the patient, may be due to valid reasons. In such cases, such behavior of the doctor, of course, cannot lead to his being brought to justice.
In forensic medical practice, there are errors, omissions and negligence in one’s duties, resulting in bodily injury, death of the patient, delay, worsening of the disease or loss of favorable time for proper treatment. These include: 1. Incorrect treatment due to misdiagnosis. Given this possibility, only those cases where such a mistake actually occurred due to inattention or due to ignorance should be punished. In contrast, one cannot be held responsible for special diagnostic rarities and accidents, which are often encountered in medical practice and, even with the most conscientious attitude, cannot be timely and accurately diagnosed due to the imperfection of our knowledge. 2. Losing the time necessary to intervene or examine the patient. Such cases include the loss of a favorable moment for surgery, for example, appendicitis, a twisted cyst, neglected transverse position of the fetus, death from bleeding due to untimely operation for an ectopic pregnancy. 3. Transmission and spread of disease due to negligence. Such examples include the transmission of syphilis or puerperal fever from one patient to another.
A number of forensic investigations and cases arise from negligence, gross negligence and ignorance. When assessing such cases, it is necessary to consider such medical actions, which in the Criminal Code are interpreted as a careless act, “careless murder”, careless infliction of injury. In the analysis of the circumstances of the case, when the nature of careless medical actions is established, it is necessary to accurately determine the presence or absence of signs of criminal negligence, which, according to paragraph “b” of Art. 10 of the Criminal Code, consist in not foreseeing the consequences of his actions, although this person should have foreseen them, or they consist in the fact that this person frivolously hoped to prevent the dangerous consequences of his actions. The inevitable medical errors in some cases, since they were unavoidable, do not give rise to a charge of criminal negligence. The concept of medical errors includes mistakes made by a doctor in his conclusions or actions in the process of performing his special medical duties without any intentionality. These errors in some cases provide grounds for criminal liability, while in other cases they do not provide such grounds. Medical errors and blunders, according to Abuladze, may be based on a number of facts that must be taken into account by the examination and a correct legal assessment must be made accordingly. The first group of errors and blunders includes fatal medical actions for the patient, which are the result of reasons that are independent of the personal qualities of the doctor who provided assistance and is held accountable. This includes moments of practical activity caused mainly by: 1) accidents or, as they say, an unfortunate combination of circumstances that cannot be foreseen in advance; 2) events that can be foreseen in advance and even prevent their development, but which cannot be eliminated by the doctor while providing assistance to the patient, 3) the lack of resourcefulness of the doctor due to the confusion that has taken hold of him during the medical procedure - some kind of operation and even acute fear due to unforeseen and unexpected complications (the so-called “operational trance” by German authors).
If medical errors and blunders are of such a nature that the doctor could not, subject to all medical requirements, foresee or prevent them, then they cannot be blamed on the doctor and be punished.
In contrast to the first, the second group includes errors and blunders that are inextricably linked with the personal qualities of the attending physician. The mistakes and blunders of this group are in the nature of various types of medical oversights, careless actions with dire consequences for patients. They can be directly related to: 1) the doctor’s lack of clinical experience and medical knowledge necessary for independent medical practice, 2) the presence of negligence and even negligence associated with haste and inattention when performing medical functions. Abuladze is absolutely right, who in his report on the legal liability of a doctor says that if a gross and sad medical error for the patient’s health was made by an inexperienced, frivolous doctor who took the liberty of providing medical intervention under his sole responsibility, without extreme necessity, such a mistake should be interpreted as an unforgivable and punishable mistake.
Thus, the line between a medical error and actual medical crimes is the absence in the first case of not only intentionality, but also imprudence and negligence in medical actions. However, due to the imperfection of medical knowledge and a number of features, at first glance, medical careless actions of a medical worker can sometimes be caused by the peculiarities of the conditions of the moment. Zelheim says about this: “If, during extraction during childbirth, the doctor, trying in every possible way to save the life of the child, acts quickly, wanting to urgently end the birth, then this can harm the mother in the form of traumatic injuries. If the same doctor, under the same conditions, performs labor slowly, wanting to ensure maximum benefit for the mother, then he thereby harms the child.”
Cases of unfair or ignorant treatment of patients are not uncommon and lead to numerous lawsuits. These cases affect not only the health or life of the victim, or the fate of the medical worker, but they discredit the whole and undermine trust in medicine and medical workers. As an example of ignorance, one can cite cases where one doctor, due to a discrepancy between the head and the pelvis, attempted to apply forceps. The forceps slipped and the doctor performed a perforation. He was unable to apply the punch, and after a number of unsuccessful attempts, the woman was taken to the hospital. During the examination, the woman was diagnosed with a uterine rupture. Help was provided at the hospital, but the patient died 15 minutes later. At autopsy, in addition to uterine rupture, extensive destruction of the intestine was discovered. It is important to emphasize that not the slightest scratch was found anywhere on the fetal head, this proves the ignorant actions of the doctor during this typical obstetric operation.
When discussing negligent acts in obstetrics, the medical examiner must particularly evaluate the limits of acceptable physiological or surgical trauma and similar injuries to the mother or fetus. It must be borne in mind that in each case, when childbirth ends with forceps, various wounds, abrasions, marks of compression can be found, and in those cases when the head is brought out obliquely, then, on the one hand, there is swelling of the eyelid, eyes, and on the other - unilateral facial paralysis. In such cases, negligent actions can only be attributed to the doctor in cases of extensive and severe injuries. Cases of obstetric errors bordering on ignorance are well known, when, for example, a fetal head tumor was mistaken for an amniotic sac and the skull was injured when it ruptured. There are also obstetric cases in which an error can be interpreted as a careless act. For example, during breech childbirth, when to remove the subsequent head, a finger is inserted into the mouth, which injures the tongue, and as a consequence of this there are cases of fatal bleeding from the vessels of the frenulum of the tongue.
With very rough obstetric interventions, there are cases of damage to the cervical vertebrae, joint dislocations, collarbone fractures, ruptures of the liver, spleen, and kidneys. Such damage can often occur with a dead or macerated fetus without any influence of trauma. On the contrary, the observation of such injuries in full-term children indicates that the obstetric intervention was crude in nature. The issue of clavicle fractures in newborns is somewhat particularly relevant. Based on special work (Dr. Tuping) at the Moscow Regional Research Institute for Maternal and Infant Protection, the following conclusions can be drawn: collarbone fractures in newborns during childbirth are a fairly common occurrence - 1.9% of all newborns. During operative childbirth this percentage increases to 4.2, and during independent childbirth it is 1.8. The causes of collarbone fractures in newborns include: 1) strong pushing activity of the mother, 2) incorrect positions of the fetus (with transverse and oblique positions, the collarbones are more likely to break), 3) too much weight of the fetus - over 3000 g, 4) method of labor management. Clavicle fractures in newborns are found more often, the more attention is paid (X-ray examination of newborns) to the possibility of such damage in newborns. It is very important to take appropriate preventive measures, namely: to exercise caution when protecting the perineum, when removing the fetus, to use infusions of petroleum jelly into the vagina at the time of eruption of the head and removal of the fetus (according to Prof. M. G. Serdyukov).
When working in obstetrics and gynecological institutions, due to negligence, unclear work or negligent attitude towards their duties, there are cases of medical personnel being brought to justice for replacing children.
To prevent such defects in work and crimes, instructions for nursing staff must be clearly drawn up and formulated in each institution, and such instructions must be persistently and punctually implemented. To prevent such replacement of children, Lee reports that in Chicago maternity hospitals it is a firm rule to designate mother and child by the same number even before cutting the umbilical cord. A metal plate with the same number is attached to the baby's umbilical cord and the mother's wrist. Previously used fingerprinting and foot impressions turned out to be of little use. At the Boston Hospital, to prevent the change of children in the delivery room, there is a supply of small sterile aluminum strips, equipped with a thread and a seal. On one side of the plate there is a death mark, and on the other side the mother’s surname is scratched into soft metal. One plate is placed on the baby's neck and the other on the mother's neck; in addition, the number is immediately entered into the medical history. Forensic medical experts, when drawing up conclusions on cases involving the transfer of children, should especially carefully pay attention to the quality of work in children's departments and the state of the internal work schedule in them, as well as the nature of labor discipline. All these factors ensure strict implementation of guidelines that prevent such unacceptable omissions as the exchange of children, which most often results from negligence or dereliction of duty by medical personnel.
The famous German obstetrician-gynecologist Selheim, drawing a differential distinction between negligence, negligence, medical ignorance and an accident, argues as follows. In cases where a doctor, during an abortion or childbirth, perforated or ruptured the uterus, this may be an accident if it is proven that he acted according to all the rules of obstetric science. In the same cases, if the doctor did not notice such a complication and did not take appropriate measures, then this is on the border of negligence. We would say that if the doctor did not notice a complication that he should have noticed under the given circumstances, then this already gives rise to a charge of criminal negligence. Often, in addition to injury and perforation of the uterus during an abortion, the intestines are injured, they are pulled out, torn, torn off and cut off. In this direction, there is an incorrect assumption that the obstetrician injured the abdominal organs exactly in the same place and within those boundaries, as was stated during the autopsy. A pathologist, a forensic expert and a judge, based on the fact that evidence of deep penetration of an instrument into the abdominal cavity during obstetric operations was discovered, often come to the conclusion that the doctor operated in a particularly crude manner - destroyed. Such conclusions always require great caution. It must be borne in mind that if there are more or less significant holes in the uterus, then the nearest hollow organs - intestinal loops - with the slightest increase in intra-abdominal pressure penetrate into the holes and, as a result of this, as well as contractions of the muscles of the uterus, the perforation hole itself can increase.
In cases of severe intestinal damage, when during abortion 6-6% of months. during perforation, significant - up to 30 cm long - intestinal loops are removed and cut off, being mixed with the umbilical cord; this is, of course, a matter of gross ignorance. The doctor’s ignorance, which caused harmful consequences for the patient, of course, provides grounds for bringing him to criminal liability, since it reveals the doctor’s dishonest attitude towards his work.
The presence of such complications in obstetrics, gynecology and surgery can sometimes be aggravated by so-called selfish actions on the part of the doctor. The absence of a selfish element is expressed in the fact that the doctor, despite the possibility of damage to his authority, strives in every possible way to save a patient with a serious complication. This does not present any great difficulties: to do this, you just need to take the patient to a suitable clinic or hospital, where she will be provided with proper assistance, of course, if such a possibility exists.
On the part of obstetric personnel (midwives, nurses), negligent actions are expressed mainly in careless disinfection of hands, instruments and other care items, and in incorrect and careless administration of medications. This plays a major role in the occurrence and spread of postpartum septic diseases, as well as septic diseases in children - umbilical infection. In addition, careless, negligent actions on the part of midwives occur in cases where the midwife, in the event of looming complications during childbirth or the postpartum period, does not call a doctor in a timely manner, but independently uses potent substances, which contributes to the development of severe complications with a fatal outcome. Forensic medical practice is rich in cases where midwives independently used pituitrin when labor was delayed without consulting a doctor. As a result, in a number of similar cases, uterine rupture occurred with fatal bleeding, since midwives could not properly assess the seriousness of the contraindications for the use of pituitrin.
Among the mass of forensic medical cases, obstetric and gynecological cases largely predominate. It would be a completely impossible task to cover all the variety of similar cases that served as material for bringing doctors to justice. Therefore, in this chapter we can only touch upon the main points of obstetric and gynecological practice, which most often provide materials for forensic medical examination.
When the uterus ruptures during childbirth, medical staff are sometimes blamed for the use of rough techniques that contributed to the rupture, as well as the failure to provide appropriate obstetric care, which resulted in a rupture, the consequences of which resulted in the death of the patient. Among the questions that the expert has to resolve in this regard, the cardinal question will be whether the uterus ruptured during childbirth independently or was it produced during an obstetric operation with a spoon of forceps or by hand during the rotation of the fetus. The main and decisive detail in such cases will be the question of correctly establishing the indications for a particular obstetric intervention and the correct technique for its use. In cases where intervention was definitely indicated, then even if a rupture occurred, the doctor may not be guilty. This can be determined by the circumstances of the case. The location and shape of the rupture do not definitively decide whether the rupture occurred artificially or independently. It is very important to consider that the uterine rupture could already exist before the intervention and could only be expanded during the intervention. Reuters reports a case where there was an independent lateral rupture of the uterus and where, during an examination of the uterine cavity, the doctor removed loops of intestine, and as a result the patient died from inflammation of the peritoneum. The doctor was prosecuted and accused of rupturing the uterus and removing the intestine. The circumstances of the case showed that the doctor was invited to the patient when she had severe symptoms in the form of cold sweat, collapse, and cessation of contractions. The court acquitted the doctor, considering that the woman did not die from the consequences of the doctor’s manipulations, i.e. not from the fact that the intestine was pulled out, but from inflammation of the peritoneum, which was the result of spontaneous rupture of the uterus. It is important for a forensic medical expert to be able to assess the clinical signs of a uterine rupture, since by the time of their appearance one can obtain valuable data for judging an arbitrary rupture or its occurrence as a consequence of one or another obstetric intervention. Signs of uterine rupture include internal bleeding (not always pronounced), shock, cessation of contractions, and detection by palpation of parts of the fetus in the abdominal cavity.
Quite often there are forensic cases involving the discovery of parts of the placenta in the uterine cavity, which served as the source of the disease - bleeding, or septic postpartum disease. In each such specific case, the doctor or midwife is accused of careless or negligent attitude towards their duties, expressed in an inattentive and unscrupulous examination of the placenta, as a result of which retained parts of the placenta remain in the uterine cavity.
On the issue of managing the third (sequential) stage of labor in modern scientific obstetrics, there are two mutually opposing opinions. The first, conservative, i.e. expectant, according to which, in case of delayed placenta and in the absence of indications (bleeding), it is customary to expect at least 2-3 hours of spontaneous separation of the placenta. If indications occur (bleeding), then immediate separation of the placenta begins, first with external methods, and if they do not succeed, then with intrauterine manual or instrumental methods. Another, more radical direction, in which they strive for the rapid release of the retained placenta and its remaining parts from the uterus. This direction is more risky and has significantly fewer followers. In France, Delmas is one of such radicalists in the management of the succession period with examination of the uterine cavity immediately after childbirth.
If, during an autopsy, pieces of placenta are discovered in the uterine cavity, the presence of which there created favorable conditions for ascending infection and the development of postpartum septic disease, the forensic medical expert is asked the main question - whether leaving pieces of placenta in the uterine cavity is negligence or a negligent attitude towards one’s duties obstetric staff. A careless or dishonest attitude towards the duties of the obstetric staff may consist in the fact that the examination of the placenta is carried out without due attention and the placenta is thrown away without such special examination. In doubtful cases, it is useful to test the integrity of the placenta using special tests for the integrity of the placenta. However, it is not always possible to completely trust such tests. In such cases, when the spontaneously discharged or removed placenta has significant defects in its tissues, even without bleeding, there is every reason to examine the uterine cavity and remove the parts of the placenta retained in it. In a number of relatively rare cases, the retention of parts of the placenta in the uterus is justified. Such cases are rare and, firstly, may represent a delay in the additional placenta, the detection of which is extremely difficult, and, secondly, the presence of placental polyps, which present many diagnostic difficulties.
In this regard, the extremely rare case of placental polyps, which caused very severe bleeding and contributed to the development of septic endometritis with subsequent general septic infection, causing death, is very interesting and instructive.
To the maternity hospital. Grauerman was admitted as a patient for childbirth, with her water breaking at home and with an increase in temperature. This is the fourth birth. In the past, the patient had many complications and, in particular, a general septic disease with thrombophlebitis after the third birth. The first period of real labor in the patient was somewhat protracted with a subfebrile course, the second and third had obvious pathology in the form of uterine atony and retained placenta, which did not separate for 8 hours. Then, when true and extensive fusion of the placenta with the walls of the uterus was established, it was isolated using internal manual techniques. From the third day, the patient showed signs of endometritis, accompanied by a sharp increase in temperature and thrombophlebitis of the left thigh. On the fifth day, the patient experienced sharp profuse bleeding twice at intervals of 8 hours, which required double curettage of the uterine cavity and tamponade. As a result of these treatments, the bleeding stopped, but the phenomena of general blood poisoning - septicemia, which began on the third day, progressed sharply and steadily, and the patient died on the 14th day. A forensic autopsy showed that the patient’s death resulted from general blood poisoning on the 14th day after urgent labor, complicated by premature rupture of water, weakness of pushing, accretion of the placenta, and severe atonic bleeding from the uterus. The causes of these complications were two “submucosal” uterine polyps, which prevented proper emptying, contraction and reverse development of the uterus. In this case, polyps served as gateways for infection, and one of them became necrosis. The infectious agents could, firstly, remain in a dormant state in polyps from previous births and abortions, as well as those complicated by the growth of placenta, or, secondly, they could be brought in from the birth canal during the necessary three-time intrauterine obstetric surgical procedures. The fatal outcome of the disease was favored by a severe degree of anemia and fatty degeneration of the heart. A microscopic examination of both polyps found in the wall of the uterus revealed that the bulk of the polyps consisted of fibrin and blood, among which separated hairs of the placenta were visible almost everywhere. In the parts closest to the wall of the uterus, strands of connective tissue are noticeable, penetrating into the fibrous-placental masses. The vessels found in this connective tissue are mostly thrombosed. In addition, the penetration of syncytial elements into the depths of the uterine wall between the bundles of muscle tissue is noticeable. In the wall of the uterus, a significant proliferation of connective tissue and vascular sclerosis is detected. Based on an accurate microscopic examination, it became completely obvious that the cause of the formation of polyps was a dense connective tissue accretion of parts of the placenta to the wall of the uterus, which occurred during pregnancy as a result of frequent inflammatory infectious processes. This is evidenced by the density of connective tissue growing from the wall of the uterus into the main tissue of the polyps and the presence of large blood vessels in the stalk of the polyps. This kind of placental polyps always poses a twofold danger: on the one hand, their forced separation can cause severe bleeding (due to rupture of the above-described large vessels), and on the other; On the other hand, such polyps, preventing the proper release of postpartum cleansing, can contribute to their delay and the proliferation of infectious principles in the uterus.
It is interesting that the husband of the deceased made extremely persistent attempts to hold the medical staff who provided assistance to the patient liable for negligence. However, a number of examinations, pointing out the rarity of this case and the thoroughness of its examination, found no signs of negligence or negligence by the medical staff and the case was closed after an investigation.
In connection with similar cases when a patient dies after childbirth or abortion from atonic unstoppable bleeding, the medical staff is blamed for not providing complete care to the patient and for not removing the uterus or not giving a blood transfusion. Each such case requires a strict individual analysis, both in terms of the sum of the measures used to stop the bleeding, and the environment in which help was provided, and the possibilities under which it was possible or impossible to perform such a responsible operation, requiring surgical technique and experience. Only if all of the above conditions were really present and with a surgical intervention suitable for anesthesia in accordance with the patient’s condition, the operation was not performed, and if the patient was not transported to the appropriate institution that could perform the operation to remove the uterus, then in such cases we can talk about negligent or negligent behavior. On the other hand, it must be borne in mind that even the operation of removing the uterus for atonic bleeding gives little encouraging results. This depends on the severe symptoms accompanying atonic bleeding in the form of shock and brain anemia.
A number of forensic cases arise where doctors are accused of being negligent or negligent in connection with cases of ectopic pregnancies. Errors or careless actions here most often arise as a result of incorrect diagnosis or untimely operation. Diagnosis of ectopic pregnancy is sometimes very difficult due to the ambiguity and confusion of symptoms. As a consequence of this and as a result of late or untimely application of the operation, such cases end in death. During a forensic medical examination, it is very important to carry out an analysis in the direction of whether all possibilities for a more precise diagnosis were used and whether they were recorded in the medical history. It is important to keep in mind whether the most important blood tests and, if time permitting, a biological pregnancy test (according to Aschheim and Tsondek) were performed. The practical value of this biological test is especially important in establishing a tubal ectopic pregnancy, when with a progressive undisturbed or disturbed pregnancy and tubal abortion, where the chorionic villi are in connection with the tubal wall, this reaction gives a positive answer. In cases of disturbed ectopic pregnancy of various ages, with the death of the egg, the organization of a blood clot, hematocele, in the absence of piles or their necrosis, this test is usually negative. Due to its great practical value, it should be used more often than has been done so far. Its only drawback is the wait for a response within 5-7 days. Friedman's reaction will give faster results.
If it is impossible to carry out tests in the current situation, then when assessing the circumstances of the case, it is important to keep in mind whether, if there was uncertainty about the diagnosis, the attending physician was provided with consultation with more experienced doctors. It should even be borne in mind that in order to preserve the health and life of the patient, cases of suspected ectopic pregnancy should be provided with constant medical supervision. Therefore, such patients should be admitted to a hospital rather than left at home. If the diagnosis is clear or if there is a high probability, the patient should be provided with prompt surgical treatment.
All these factors must be taken into account and compared with the situation and objective capabilities surrounding the doctor who provided care to the patient.
In forensic medical practice, there are cases of prosecution under Article 111. Criminal Code for the negligence of doctors due to incorrect diagnosis of maternity leave during pregnancy. A similar case was described by Dr. Rosenblum (see Bulletin of Modern Medicine No. 14, 1929). The interest of the case lies, by the way, in the fact that the commission that granted the leave consisted of therapists. To eliminate such cases, it is important that every obstetrician knows how to determine the timing of pregnancy. In such cases, correct data on the first day of the last menstruation and early attendance of the pregnant woman at the consultation are important. The doctor is required to strictly adhere to and know the methodology for determining the duration of pregnancy in order to provide maternity leave.
A significant number of medico-legal cases arise where medical personnel are accused of being negligent and negligent in the occurrence of septic diseases. In a number of cases arising in this direction, the onset and occurrence of septic disease is associated with the contact actions of medical staff: delivery, performance of one or another obstetric, gynecological or general surgical operation. In addition, in a number of cases of septic diseases, medical personnel are accused of untimely, incorrect recognition with incorrect subsequent treatment, which results in death, which is also classified as careless or negligent attitude towards their duties. When examining such, often very complicated, cases, a thorough analysis of each individual case is required. Here the question of the patient’s condition before childbirth, before operations and abortion, plays an important role. It is necessary to reject or establish the possibility of bacilli carriage, foci in the oral cavity (teeth, tonsils, sore throat, etc.) or other foci, for example, in the kidneys (pyelitis), etc., which may, under the influence of surgical trauma, anesthesia, blood loss and internal research to generalize septic disease. In addition, when forensically diagnosing the routes of septic infection, one must take into account the condition in which the patient was admitted to the institution before childbirth or surgical intervention. For example, the presence of increased temperature, dirty water, increased heart rate before childbirth indicate signs of an inflammatory and infectious disease on the part of the uterine mucosa.
When assessing the direct culpability and course of action of medical personnel in a particular case of septic disease, in addition to the above considerations, the environment in which the septic disease occurred, the frequency of septic cases (morbidity and mortality) in the institution where medical care was provided to the patient, and The direct characteristics of the activities of medical staff are important. When performing a forensic medical analysis of each individual case of septic postpartum or post-abortion infection, one should keep in mind the possibility of “self-infection” in the sense of Kaltenbach’s teaching. Modern scientific opinions on the possibility of so-called “self-infection” or “conditionally endogenous infection” differ. Some recognize this rare opportunity, others deny it altogether. When objectively assessing this path of occurrence of septic disease, it is necessary to point out that it is impossible to completely deny this possibility of self-infection of the body. However, such cases are 1) rare, 2) they can claim reliability only when the research data are recorded in a fully compiled medical history and the circumstances of the case exclude any possibility of exogenous infection.
When forensic medical so-called “septic” cases arise, a number of questions are raised, in particular, accusations of negligence and negligent attitude towards the patient, and then, if a seriously septic patient in the midst of an illness is transferred from one medical institution to another, as a result of which (thrombophlebitis ) the condition deteriorates and the case ends in death. There is no doubt that in cases of septic acute purulent venous disease, transportation of patients is contraindicated, and if it is carried out in pursuance of an advisory decision, then such transportation must be carefully carried out and be accompanied by all precautions.
A number of cases arise in connection with surgery. In this matter, the position according to which any planned operation must certainly be carried out should be considered firmly established; with the consent of the patient. Only when emergency surgical care is provided, and also when the patient is unconscious due to blood loss (internal bleeding during an ectopic pregnancy, uterine rupture) or when due to other acute diseases (volvulus, twisted cyst, pinched posteriorly curved uterus) the patient is in in a darkened state, the doctor is obliged to provide help without necessarily obtaining the patient’s consent. However, in such cases, if time and situation permit, the patient’s relatives should be warned. The second fundamental issue and, of course, mandatory for the doctor providing surgical assistance should be every effort to remove only the changed tissue organs, while preserving healthy ones. However, this principle has a lot of conditionality in it and is sometimes difficult to implement in practice, since, firstly, sometimes it is very difficult to determine the extent of the lesion by eye, and therefore, in case of malignant tumors or if malignant degeneration is suspected, it is better to act more radically during surgical treatment. Further, there are cases when, with extremely careful treatment, the surgeon leaves what appears to him to be a healthy part of the tissue of a very important organ or gland. For example, with cystic degeneration of the ovary, part of it is left, since complete removal would deprive the woman of her main function - menstruation - and would cause severe changes in the entire body. With this conservative course of action, sometimes after 1-2 years or earlier a new tumor - a cyst - can form. This gives patients a reason to accuse the doctor of careless or imprudent actions, as a result of which the patient must be exposed to a new operational risk. Of course, apart from clearly rude actions in this direction based on the indications or surgical technique, the doctor cannot be blamed for a relapse of the disease.
Interesting from a forensic medical point of view is the examination of the accusation against doctor G. of improperly performing an operation in the city of O. The main point against him was the immoderate surgical radicalism regarding the removal of the ovaries. On this occasion, the main material was five case histories of patients who were operated on by doctor G. It is interesting to point out that four commissions worked on this case in the city of O., which did not give a clear and objective opinion. Therefore, the NKJ handed over all the materials to the NKZdrav for a final conclusion. The forensic medical expert commission at the NKZdrava gave the following opinion about these five cases based on the study of medical histories and examination of one patient - the complainant in this case.
Case 1. U gr. 10 years ago, uterine fibroids were diagnosed. This tumor increased and uterine bleeding appeared. Upon admission to the hospital, multiple uterine fibroids the size of an adult’s head were diagnosed. During the operation, the tumor was removed, and the painfully altered ovaries (with cystic degeneration) were punctured. The postoperative period proceeded smoothly. After 8 months, gr. Severe symptoms of pelvic congestion with general, predominantly nervous symptoms were noted. After 3 months, gr. The Moscow Bureau of Medical Examination confirmed presenile psychosis with delusional symptoms, arteriosclerosis, postoperative white line scar, and absence of the uterus. At the State Institute of Experimental Endocrinology, where Ms. H-h, she has been diagnosed with menopause, hyperthyroidism, abdominal adhesions. The expert commission at the NKZdrava, which examined gr. G-h, found: a strengthened postoperative scar of the white line of the abdomen, absence of the uterine body after supravaginal amputation for multiple uterine fibroids, hyperthyroidism. These data allowed the commission to say that the operation performed by gr. G-h a year ago, was indicated, performed correctly and, according to an objective study, with good results in the operational area (genital organs).
Case 2. U gr. Mr., 16 years old, began to experience severe uterine bleeding, which continued to increase upon admission to the hospital (January 31, 1931) and during the first time of his stay in the hospital until February 9, 1931, when it became life-threatening. Despite the use of various conservative treatment methods, the bleeding did not stop. On February 9, 1931, the third operation was performed: dissection of the hymen, dissection of the cervical canal, tight utero-vaginal tamponade. The bleeding stopped, and gr. G. was discharged healthy. The commission came to the conclusion that there was acute severe bleeding in adolescence, which did not respond to correctly applied conservative treatment, which is why the operation performed on her was indicated and gave positive results.
Case 3. Gr. Sh., 20 years old, suffered from gonorrhea. She was treated for inflammation of the ovaries (douching, tampons, flies). Once, curettage was performed for therapeutic purposes. She was admitted to the hospital with complaints of severe pain in the groins that had lasted three years. During the examination, it was discovered: on the left in the area of the uterine appendages - a cyst, on the right in the area of the uterine appendages - adhesions. During the operation it was discovered: the left appendages in the form of a tubo-ovarian tumor are in fusion with the parietal peritoneum, the right tube is stretched at the ampullary end to the size of a chicken egg, filled with bloody fluid. Removed: on the left the tube and ovary, on the right - the tube. The expert commission found that gr. Sh. had a chronic disease of the uterine appendages due to gonorrhea. The process lasted three years, during which she underwent treatment without success. Currently, regarding the treatment of such cases, there are two directions: some doctors adhere to surgical methods of treatment, others - conservative methods with prolonged use, up to several years, of various therapeutic measures (resorts, mud, etc.). Both methods are used in practice, and there is no reason to see incorrect actions in the operation performed by Dr. G. gr. Sh.
Case 4. Gr. S., 23 years old, was admitted to the hospital with complaints of pain in the lower abdomen, left and lower back. Considers himself sick for three years. The pain appeared after suffering a postpartum illness (I was sick for 4 months). Recently, the pain has intensified and vaginal discharge has increased. A gynecological examination revealed: on the right, the uterine appendages in adhesions were enlarged, on the left, a tumor of cystic consistency the size of a fist. During the operation on the right, the appendages that were in adhesions were removed, and the ovary was in the form of a thin-walled cystic tumor, together with the tube, attached to the serous membrane of the large intestines. The left tube, filled at the ampullary end with yellowish contents, was also removed. The expert commission expressed the same opinion about this case as in the previous one, considering that the doctor’s choice of one or another method is accepted in practical medicine and cannot be interpreted as an incorrect action.
Case 5. gr. A., 35 years old, six months before admission to the hospital there was inflammation of the ovaries. She was admitted with a complaint of pain in the lower abdomen and spotting that lasted for one and a half months. During a gynecological examination in the hospital, it was found: there is bloody discharge, the uterus is deviated posteriorly, enlarged, dense, protruding, the pharynx is slightly open. The uterine appendages are slightly painful. The patient underwent curettage surgery of the uterine mucosa. The forensic medical expert commission made a conclusion on this matter: gr. A., there was a posterior tilt of the uterus and there was chronic inflammation of the uterus and its mucous membrane with irritation of the appendages, accompanied by prolonged (1% of the month) persistent bleeding. There were no direct indications for surgical intervention in this case, and it would have been more careful and careful to have conducted preliminary observation of the patient in the hospital using conservative treatment methods, although the treatment method used by the doctor, judging by the medical history, gave a positive result.
From forensic medical practice in connection with the performance of additional operations, in particular when removing the uterus due to wounds and perforation, sometimes accusations arise of excessive radicalism, depriving a woman of a very important organ for her (the uterus).
In this regard, I will give one interesting case. To the maternity hospital. Grauerman was admitted to patient S., 21 years old, with elevated temperature, rapid pulse, abdominal pain, and significant bleeding. It was found out that an unknown doctor performed an abortion on her at home in the fourth month of pregnancy. It turned out that during the abortion, gr. S. the uterus was perforated and the omentum was pulled out through this hole twice. In view of the obvious discrepancy between temperature and pulse, the presence of pain, the possibility of injury to the viscera, because the omentum was removed, and also because the case was considered infected, the most correct path in such doubtful cases was chosen - transection, to which the patient gave her consent in writing. During the operation, about 60 cm3 of dark turbid blood was found in the abdominal cavity, parts of the omentum were softened and bruised, and a perforated hole in the uterus of a peculiar nature was found in the uterus, obliquely penetrating under the bladder. This hole allowed one and a half fingers through, therefore the anterior wall of the neck was destroyed. Under the above conditions, i.e. in the presence of a wound of the uterus penetrating into the abdominal cavity, made “at home”, in the presence of signs of active infection, on the one hand, and with the unique location of the cervical wound, on the other, it was not possible to save the infected organ and the uterus without risk to the patient had to be removed. This course of action was also prompted by the fact that the uterus contained almost the entire fetus and afterbirth, so emptying it through the abdominal cavity would have threatened with even greater infection of the peritoneum. Finally for the third possibility, i.e. to complete the abortion (despite the perforation) through the vagina with the subsequent use of transection for conservative suturing of the cervix, there were no technical conditions due to the unique nature of the wound and the presence of uterine infection. The uterus was removed along with the right ovarian cyst, and the wounded areas of the omentum were resected. The patient recovered.

The course of action was correct, since later, when assessing the pathological specimen, it turned out that the lower segment of the uterus was extremely traumatized. Here there was not only perforation and abandonment of most of the fetus, but also deep stripping of the muscular part of the uterine wall, as can be seen in Fig. 27. It is very interesting that the accused doctor and part of the non-objective examination tried to raise the question that in this case it would be possible not to remove the uterus.
The prosecutor further explained that if in medicine there are two, even opposite, methods of treatment, then the attending physician, in accordance with his experience and conviction, can choose one or another method aimed at preserving the health and life of the patient.
A certain number of so-called “surgical forensic” cases are due to the abandonment and forgetting of tampons and instruments, mainly in the abdominal cavity. There is a large literature on this subject, in which such cases are analyzed from different angles, and the conditions under which such facts can be accidental are discussed, and vice versa, when they should certainly be considered a careless or negligent act. As a rule, of course, such actions constitute a crime on the part of a doctor. However, during the forensic medical investigation of such cases, it is necessary to establish or reject various unforeseen complications during surgery in the form of special adhesions, extreme bleeding, respiratory arrest, etc. All this can cause a weakening of concentration, distraction of the surgeon and his assistants from the surgical field. Of great importance, as revealed by special studies, is the time of operation (day, night), the qualifications of the support staff, as well as the material - the quality of the instruments (fragility of needles, curettes and other instruments). Tampons were much more likely to be forgotten during emergency overnight surgeries than during daytime elective surgeries. It is important to note that when analyzing the qualifications of the surgeons in whom such cases occurred, it turns out that the abandonment of tampons and instruments occurred among the greatest specialists, and such cases predominantly occurred in the second half or at the end of the work of very experienced surgeons. In this matter, when establishing the fact of accident or negligence, the surgical environment in which the surgeon operated plays a role. During so-called “tour” operations, when a surgeon operates with personnel who are unadapted and have not worked well with him, the possibility of leaving or forgetting tampons or instruments is much greater than during an operation in a usual environment for a surgeon with someone who has worked well and is accustomed to his methods. and requirements of medical staff. The fact of negligence and negligence when leaving tampons and instruments can occur if the internal rules for operational activities do not take measures to prevent this in the work of the operating room, in particular, if there is no accurate accounting of tampons, there is no punctual counting of instruments, etc., There is no periodic inspection of the suitability of instruments and timely removal of fragile instruments. Recently, in Germany, in order to prevent or, rather, quickly diagnose such cases, a special gauze with a thin soft metal thread has been introduced, which can be easily diagnosed using X-rays. Pieces of such gauze, when left in the body cavity of animals, as proven by trial experiments, are easily diagnosed and visible on radiographs. Thus, in this matter, a forensic medical examination must take into account in detail the circumstances surrounding the abandonment of a foreign body in order to give a conclusion about the accident of such a fact or to establish elements of negligence and negligent attitude.
As a new, but self-justifying method in assessing the nature of the actions of a surgeon who has made a gross mistake or careless manipulation, who has allowed a foreign body to be forgotten in the cavity during an operation, a psychotechnical examination of the person involved or accused can be used.
In this way, with the help of special tests, the degree and acuity of attention, observation, fatigue and a number of other mental abilities can be determined. In this case, completely unexpected, but important data may be obtained (for example, color blindness); the fact of congenital or acquired defectiveness of certain abilities important for the surgeon’s technique may be established.
Such psychotechnical examinations have long been used in the selection and assessment of suitability for serious professions (drivers, drivers, pilots, etc.).
This should equally be put into practice when assessing the suitability of workers for other industries, in particular surgery, obstetrics, gynecology, etc.
Among the issues related to the resolution of surgical cases, the examination most often has to establish the presence or absence of inattention and negligence of medical actions. In this direction, Prof. Raisky gives a list of questions in which there are signs of inattention on the part of the doctor. There will be inattention on the part of the doctor during any examination, in particular when establishing a diagnosis: a) failure to use the technical means at the doctor’s disposal, all kinds of research when there were indications for this, b) failure to consult with a more experienced colleague, if this was necessary and perhaps c) establishing a diagnosis “by eye”, i.e. when the patient was little or not examined at all. To the doctor’s courage in the field of surgical intervention, turning into “therapeutic mischief,” Prof. Raisky refers to: 1) heavy operations without sufficient indications, 2) responsible operational assistance, i.e. carrying out large heavy operations that do not require haste, by a person who is completely unprepared for this; 3) carrying out important operations that do not require haste, in a completely unacceptable environment.
The forensic expert is faced with the question of the admissibility of using one or another newly proposed method (for example, cadaveric blood transfusion) in order to improve the patient’s condition or use a new medicinal substance imported or invented in the USSR. At the same time, the main position still remains: the inadmissibility of direct experimentation on a sick person. The use of any newly proposed medicinal substance or method is permissible only if the following conditions are met: 1) after all biological tests with this drug have been carried out and tested on animals, an adjustment has been made in doses, and the effect on the human body has been taken into account; 2) the use of a new substance must be carried out with the knowledge and permission of the health authorities - NKZdrava; 3) the use of a new substance for therapeutic and diagnostic purposes must be carried out with the obligatory consent of the patient or his relatives, if the patient himself is unconscious or in a darkened state. The use of various medications and therapeutic agents of unknown, secret composition on humans is certainly unacceptable until the composition of the drug is clarified and chemically clear.
In conclusion, it must be said that this chapter only makes an attempt to generalize those most common cases from obstetric-gynecological treatment and research work that can serve as a reason for bringing medical workers to justice. Due to lack of space, I was unable to provide more examples and other factual material. In this chapter, I touched only on the most frequently cited examples of forensic errors in court and in the medical press, using my extensive experience. I distinguished careless actions, negligence, as subject to criminal liability, from medical errors that do not involve criminal negligence, which can occur in any work.
In forensic medical examination, there are undoubtedly a number of significant difficulties encountered, due to the fact that many practical issues are based on the achievements of theoretical medicine, and the latter are largely inaccurate since much is still beyond the limits of our modern ones; knowledge.
For an accurate clarification of the circumstances of the case, it would be important to have a provision according to which the investigative bodies: 1) would pose questions to the expert examination within the limits of the possibility of solution, 2) would use more frequent medical examination in the process of conducting the investigation itself. This direction, of course, could contribute to a more accurate and complete elucidation of the essence of often complex forensic cases.
The interests of protecting the life and health of workers, of course, require not only that the guilty health worker be appropriately punished, and that the innocent one not be persecuted, but, on the contrary, be protected in every possible way. In this matter, the amount of measures that can reduce the number of medical errors to negligible limits and prevent ignorant actions of medical personnel that are detrimental to the life and health of workers is of great importance. For these purposes, it is important to implement nationwide measures for constant retraining and advanced training of higher (medical), middle (midwives, nurses, physician assistants) and junior (for example, nurse) medical staff. A whole series of forensic medical cases owed their existence to the fact that novice doctors do not know enough about medical practice, that they are poorly prepared for practical work. This is partly because there is not enough time during training for in-depth practical work. It is absolutely clear that a one-time punishment of an inexperienced doctor is not a way out of the situation. The next time this same doctor, with insufficient knowledge of obstetrics and gynecology, taking on some other case, will again cause harm to both mother and child. Refusal from obstetrics in such cases, voluntary or forced for the incapable or inexperienced, is not a punishment, but only a precautionary measure in relation to the population and does not completely solve the issue from a medical point of view. A whole range of medical cases here and abroad makes it necessary to point out once again that there is a need for rapid and constant practical courses for doctors, midwives and nurses in order to bring them to the level of the current state of science and to instill in them proven practical skills. Only in this way and by punishing the unconditionally guilty violators can the desired result be achieved.

Application
APPROVED AGREED
Deputy People's Co-Prosecutor of the RSFSR
Missar of Health Antonov-Ovseenko
M. Gurevich December 31, 1934 No. 14739-